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Kaisorn L. Chaichana, Mohamad Bydon, David R. Santiago-Dieppa, Lee Hwang, Gregory McLoughlin, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan, and Timothy Witham

, 46 These previous studies confound the true incidence of infections for posterior lumbar instrumented fusion because they include patients with different pathological entities such as tumors and trauma, 6 , 36 patients who underwent nonlumbar procedures, 22 , 34 and patients who did not undergo instrumented fusion. 12 , 30 Therefore, it is difficult to interpret the risk of spinal infection for patients who are undergoing posterior lumbar fusion for degenerative spine disease, which is the most common type of fusion procedure. 9 , 35 The goals of this study

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Patrick C. Reid, Simon Morr, and Michael G. Kaiser

Lumbar fusion is an accepted and effective technique for the treatment of lumbar degenerative disease. The practice has evolved continually since Albee and Hibbs independently reported the first cases in 1913, and advancements in both technique and patient selection continue through the present day. Clinical and radiological indications for surgery have been tested in trials, and other diagnostic modalities have developed and been studied. Fusion practices have also advanced; instrumentation, surgical approaches, biologics, and more recently, operative planning, have undergone stark changes at a seemingly increasing pace over the last decade. As the general population ages, treatment of degenerative lumbar disease will become a more prevalent—and costlier—issue for surgeons as well as the healthcare system overall. This review will cover the evolution of indications and techniques for fusion in degenerative lumbar disease, with emphasis on the evidence for current practices.

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Meghan E. Murphy, Hannah Gilder, Patrick R. Maloney, Brandon A. McCutcheon, Lorenzo Rinaldo, Daniel Shepherd, Panagiotis Kerezoudis, Daniel S. Ubl, Cynthia S. Crowson, William E. Krauss, Elizabeth B. Habermann, and Mohamad Bydon

OBJECTIVE

With improving medical therapies for chronic conditions, elderly patients increasingly present as candidates for operative intervention for degenerative diseases of the spine. To date, there is a paucity of studies examining complications in lumbar decompression, without fusion, that include patients older than 80 years. Using a multicenter national database, the authors of this study evaluated lumbar decompression in the elderly, including octogenarians, to evaluate for associations between age and patient outcomes.

METHODS

The 2011–2013 American College of Surgeons' National Surgical Quality Improvement Program data set was queried for patients 65 years and older with diagnosis and procedure codes inclusive of degenerative spine disease and lumbar decompression without fusion. Morbidity and mortality within the 30-day postoperative period were the primary outcomes. Secondary outcomes of interest included unplanned readmission within 30 days or discharge to a nonhome facility. Outcomes and operative characteristics were compared using chi-square tests, Kruskal-Wallis tests, and multivariable logistic regression models.

RESULTS

A total of 8744 patients were identified; of these patients 4573 (52.30%) were 65 years and older. Elderly patients were stratified into 3 age categories: 85 years or older (n = 314), 75–84 years (n = 1663), and 65–74 years (n = 2596). Univariate analysis showed that, compared with age younger than 65 years, increased age was associated with the number of levels (≥ 3), readmissions within 30 days, nonhome discharge, any complication, length of stay, and blood transfusion (all p < 0.001). On multivariable analysis and with younger than 65 years as the reference, increased age was associated with any minor complication (p < 0.001; ≥ 85 years: OR 3.47, 95% CI 1.69–7.13; 75–84 years: OR 2.34, 95% CI 1.45–3.78; and 65–74 years: OR 1.44, 95% CI 0.94–2.20), as well as discharge location other than home (p < 0.001; ≥ 85 years: OR 13.59, 95% CI 9.47–19.49; 75–84 years: OR 5.64, 95% CI 4.33–7.34; and 65–74 years: OR 2.61, 95% CI 2.05–3.32).

CONCLUSIONS

The authors' high-powered, multicenter analysis of lumbar decompression without fusion in the elderly, specifically including patients older than 80 years, demonstrates that increased age is associated with more extensive operations, resulting in longer hospital stays, increased rates of nonhome discharge, and minor complications.

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Sebastian Carlos Ranguis, Dianna Li, and Angela Claire Webster

the first systematic review on the topic, a small review with similar findings was discussed by Rasmussen et al. 43 The present study is the first review to report that epidural steroids significantly decrease the total postoperative consumption of analgesic agents following lumbar spinal surgery for degenerative spine disease. Despite a case series linking epidural steroids to an increased incidence of adverse events such as wound infection, 30 in our systematic review we found no difference in the risk of reported adverse events. Several methodological

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Joseph H. Piatt Jr.

hydrocephalus included shunt insertion, shunt revision, shunt removal, ventriculocisternostomy, and external ventricular drainage (02.2, 02.31–02.35, 02.39, 02.41–02.43, and 54.95). Surgery for degenerative spine disease included cervical and lumbar disc surgery, cervical fusions excluding atlantoaxial fusion, and lumbosacral fusions (03.02, 03.09, 80.50–80.52, 80.59, 81.02, 81.03, 81.06–81.08, 81.32, 81.33, 81.36–81.38, 84.58, and 84.60–84.64). Surgery for spinal cord conditions included surgery for tethering and for syringomyelia (03.4, 03.51, 03.52, 03.59, 03.6, 03.7, 03

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Paul G. Matz, Paul A. Anderson, Michael G. Kaiser, Langston T. Holly, Michael W. Groff, Robert F. Heary, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic, and Daniel K. Resnick

T he surgical treatment of degenerative spine disease has increased in frequency and complexity. Using data from the National Hospital Discharge Survey, Davis 2 reported a > 70% increase in age-adjusted cervical fusion rates and a > 45% increase in rates of hospitalization for cervical spine surgery between 1979 and 1990. Angevine et al. 1 examined National Hospital Discharge Survey data between 1990 and 1999 and noted that the age-adjusted rates for cervical surgery remained the same throughout the decade but that the rates of fusion increased 40% in

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Haroon Fiaz Choudhri and Lance Harlan Perling

✓ Juxtafacet cysts are lesions that are associated with spinal facet joints. Although these lesions are frequently noted as incidental findings on imaging studies of the spine, they may produce symptoms in some patients. Juxtafacet cysts can mimic herniated discs, resulting in symptoms from focal nerve root and/or spinal cord compression. Some of these lesions are associated with spinal instability, and patients may require spinal fusion to address this underlying disorder. Conservative therapy for symptomatic lesions is often unsuccessful, although there are reports of spontaneous resolution of these cysts as well as the symptoms associated with them. Surgical therapy should be focused on decompression of the lesions causing nerve root compression and the accompanying symptoms, while recognizing that instability requiring fusion may be present in some but not all cases.

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Patrick C. Hsieh, Tyler R. Koski, Brian A. O'Shaughnessy, Patrick Sugrue, Sean Salehi, Stephen Ondra, and John C. Liu

Object

A primary consideration of all spinal fusion procedures is restoration of normal anatomy, including disc height, lumbar lordosis, foraminal decompression, and sagittal balance. To the authors' knowledge, there has been no direct comparison of anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) concerning their capacity to alter those parameters. The authors conducted a retrospective radiographic analysis directly comparing ALIF with TLIF in their capacity to alter foraminal height, local disc angle, and lumbar lordosis.

Methods

The medical records and radiographs of 32 patients undergoing ALIF and 25 patients undergoing TLIF from between 2000 and 2004 were retrospectively reviewed. Clinical data and radiographic measurements, including preoperative and postoperative foraminal height, local disc angle, and lumbar lordosis, were obtained. Statistical analyses included mean values, 95% confidence intervals, and intraobserver/interobserver reliability for the measurements that were performed.

Results

Our results indicate that ALIF is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The ALIF procedure increased foraminal height by 18.5%, whereas TLIF decreased it by 0.4%. In addition, ALIF increased the local disc angle by 8.3° and lumbar lordosis by 6.2°, whereas TLIF decreased the local disc angle by 0.1° and lumbar lordosis by 2.1°.

Conclusions

The ALIF procedure is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The improved radiographic outcomes may be an indication of improved sagittal balance correction, which may lead to better long-term outcomes as shown by other studies. Our data, however, demonstrated no difference in clinical outcome between the two groups at the 2-year follow-up.

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Michael C. Dewan, Abbas Rattani, Ronnie E. Baticulon, Serena Faruque, Walter D. Johnson, Robert J. Dempsey, Michael M. Haglund, Blake C. Alkire, Kee B. Park, Benjamin C. Warf, and Mark G. Shrime

)  Entirely administrative or research 1 (1)  Retired, other 2 (2) Patient payer status, primary (n = 85)  Public 53 (62)  Private 14 (16)  Both about equal 18 (21) Patient age epoch, primary (n = 85)  Adult 45 (53)  Pediatric 14 (16)  Both about equal 26 (31) Most commonly treated conditions * (n = 87)  Brain tumors 57 (66)  Traumatic brain injury 51 (59)  Hydrocephalus 41 (47)  Degenerative spine disease 38 (44)  Congenital malformations 21 (24)  Traumatic spinal injury 17 (20)  Vascular anomalies 16 (18)  Stroke 10 (11)  Spinal tumors 8 (9)  Epilepsy 6 (7)  Pain

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Daniel K. Resnick and Lincoln F. Ramirez

students to subspecialists. The resulting irony of this shift is that medical students now have diminished opportunities to learn directly from the specialists that they are supposed in part to supplant. With regard to neurosurgery, this means that today's graduating medical student may not be optimally prepared to deal with commonly encountered conditions such as CA disease or degenerative spine disease. Furthermore, the student may not be prepared for prompt recognition of other conditions. Knowledge of SAH and tumor- or hydrocephalus-related ICP is invaluable when